Nursing Theorist Dorothea Orem SelfCare Deficit Theory Presented

Nursing Theorist: Dorothea Orem Self-Care Deficit Theory Presented by MSN Students: Cheryl L Holz RN, BSN Anna Marshall RN, BSN

Dorothea Orem 1914 - June 22, 2007 Born in Baltimore, Maryland Died at home in Skidaway Island ØEducation: ØDiploma (early 1930's) Providence Hospital School of Nursing, Washington, DC ØBSN Ed. (1939) and MSN Ed. (1945) from the Catholic University of America, Washington, DC.

Credentials & Background ØHonorary Doctorates: ØDoctor of Science from Georgetown University (1976) and Incarnate Word College in San Antonio, Texas (1980) ØDoctor of Humane Letters from Illinois Wesleyan University, Bloomington, Illinois (1988) ØDoctor Honoris Causae, University of Missouri. Columbia (1998).

Credentials & Background ØSpecial Awards: ØCatholic University of America Alumni Achievement Award for Nursing Theory (1980) ØLinda Richards Award, National League for Nursing (1991) ØHonorary Fellow of the American Academy of Nursing (1992).

Early Nursing Experiences Ø Clinical Ø OR Ø Private Duty Nursing (home & hospital) Ø Staff nursing (pediatric & adult medical and surgical units) Ø Evening supervisor-ER Ø Education: Ø Biological science teacher Ø Assistant Director of School of Nursing Ø Consulting: Ø Indiana St. Board of Health (1949 -1957) Ø Office of Education, US Department of Health, Education, and Welfare (1957 -1959)

Theoretical Sources & Influences Ø Eugenia K. Spaulding-great friend & teacher only Ø Cites no particular nursing leader as a direct influence on her work. Ø Does cite many other nurses’ works in terms of their contributions to nursing: Ø Abdullah, Henderson, Johnson, King, Levine, Nightingale, Orlando, Peplau, Riehl, Rogers, Roy, Travelbee, and Weidenbach, et al Ø Cites numerous other authors from other disciplines: Ø Chester Barnard, Rene’ Dubos, Robert Katz, Ernest Nagel, Hans Selye, Ludwig von Bertalanffy, et al

Theoretical Sources & Influences-cont’d Ø Human organization, action theory ØAn area of philosophy concerned with theories about the processes causing intentional/willful human bodily movements of more or less complex kind http: //en. wikipedia. org/wiki/Philosophy_of_action, retrieved 10/10/08

Theoretical Sources & Influences-cont’d Ø The works of: Ø Aristotle Ø Thomas Aquinas Ø Barnard (1962) Ø Kotarbinski (1965) Ø Macmurray (1957) Ø Parson, Bales, and Shils (1953) Ø B. J. F Lonergan’s Insight(1958) [on reflective thinking], Ø Assays by Wallace (1979, 1983) [for recent clarifications]. Orem, D. E (1987). Orem’s general theory of nursing. (p. 73)

Origins 1949 -1959 Ø Began to develop ideas regarding the uniqueness of nursing Ø In effort to formalize a framework by which to organize nursing knowledge, she asked the following questions…

Origins Ø “What is nursing? ” Ø “How was it different from other disciplines? Ø “How was it similar? ” Ø “What is the domain and what are the boundaries of nursing as a field of practice and a field of knowledge? ” Ø “What condition exists when judgments are made that people need nursing? ”

Ideas evolved from: Ø Unique experiences of her personal nursing career Ø Observations in practice Ø Study of formal logic and metaphysics Ø Use of resources from many fields Ø Abilities in methods of reflect and questioning Ø Collaborations with students, practitioners, researchers, educators, administrators and scholars

Formalization Ø 1960 -1980 Ø through extensive reading and self-reflection Øcollaborations with students, practitioners, researchers, educators, administrators and scholars

Publications Ø 1971 -Nursing: Concepts of Practice Ø Editor for Nursing Development Conference Group (NDCG)-prepared & later revised Concept Formalization in Nursing: Process and Product Ø 1980, 1985, 1991, 1995, and 2001 - subsequent editions of Nursing Concepts of Practice Ø 1984: Orem retired

Practice Ø First documented use: Ø 1973 -John Hopkins Hospital ØIn nurse-managed clinics Ø Various clinical populations & age groups ØNeonates to the elderly ØHealth promotion practices & care of the sick (The nursing management of pertussis was described from the SCDNT perspective).

Practice-cont’d Ø Ethnically & culturally diverse populations ØOrem’s SCDNT: translated into Italian, French, Spanish, Dutch, and Japanese ØCurrently, translations of some or all of her most recent work in Germany, Thailand, and Norway, et al. ØUsed throughout the world ØGreat Britain, Taiwan, Thailand, Japan, Korea, Canada, Australia, New Zealand, South Africa, Israel, Germany, Spain, Italy, France, Belgium, the Netherlands, Bolivia, Colombia, Uruguay, and Mexico

Central Philosophy Ø The philosophy of Orem’s SCDNT is based upon: Ø“patients wish to care for themselves” Ø“moderate realism”

Conceptual Theoretical Model R=relationship; <=deficit relationship, current or projected (Tomey & Alligood, 5 th Ed. , 2002, pg 192) R Conditioning Factors Self-Care R R Self-Care Agency < Self-Care Demands Deficit R R Conditioning Factors Nursing Agency Conditioning Factors

Internal/External Stimuli

SCDNT: A General Theory Composed of Three Related Theories Ø THEORY OF SELF-CARE: Ø How and why people care for themselves. Ø THEORY OF SELF-CARE DEFICIT: Ø Describes and explains why people can be helped through nursing. Ø THEORY OF NURSING SYSTEMS: Ø Describes and explains relationships that must be brought about and maintained for nursing to be produced.

Three Types of Nursing Systems Ø Wholly Compensatory Ø Doing for the patient Ø Partially Compensatory Ø Helping the patient do for him/herself Ø Supportive-Educative Ø Helping the patient learn to do for him/herself

Concepts & Principles Ø SELF-CARE: ØActivities individuals do on a daily basis within time frames, on their own behalf ØIn the interest of maintaining life & healthful functioning ØTo continue personal development & well being

Concepts & Principles-cont’d Ø SELF-CARE REQUISITES (SCRs): Ø Groups of needs or requirements Ø Classified as: ØUNIVERSAL SELF-CARE REQUISITES Ø those needs all individuals have (six SCR common to men, women, and children) ØDEVELOPMENTAL SELF-CARE REQUISITES Ø those needs that relate to the development of the individual ØHEALTH DEVIATION REQUISITIES Ø those needs that arise as a result of an individual’s condition

Concepts & Principles-cont’d Ø THERAPEUTIC SELF-CARE DEMAND: Ø Controlling or managing factors identified in the requisites; the values of which are regulatory of human functioning (air, water, and food) Ø Fulfilling the activity element of the requisite (maintenance, promotion, prevention, and provision)

Concepts & Principles-cont’d Ø SELF-CARE AGENCY: Ø“Complex acquired ability to meet one’s continuing requirements for care that regulates life processes, maintains or promotes integrity of human structure and functioning and human development, and promotes well-being. ” (Marriner-Tomey, 1994, pg. 184)

Concepts & Principles-cont’d Ø AGENT: Ø“The person taking action” Ø SELF-CARE AGENT: Ø“The provider of self-care” Ø DEPENDENT-CARE AGENT: Ø“The provider of infant care, child care, or dependent adult care”

Concepts & Principles-cont’d Ø SELF-CARE DEFICIT: ØWhen a patient is very unable to meet their own self-care requisites (refer to slide 21) Ø NURSING AGENCY: ØEducated nurses ØAbility to act, know, & help patients

Concepts & Principles-cont’d Ø NURSING DESIGN: ØProfessional function (done before and after nursing diagnosis and prescription)ØBasis of reflective practical judgments ØPurposeØProvide guides for achieving needed and foreseen results in production of nursing toward the achievement of nursing goals

Concepts & Principles-cont’d Ø NURSING SYSTEMS: ØConstructed through actions of nurses and nursespatients. ØDeliberate practical actions of nurses ØPerformed at times in coordination with actions of their patients to know & meet components of their patient’s therapeutic self-care demands. ØTo protect and regulate the exercise or development of patient’s self-care agency

Conceptual Theoretical Model R=relationship; <=deficit relationship, current or projected (Tomey & Alligood, 5 th Ed. , 2002, pg 192) R Conditioning Factors Self-Care R R Self-Care Agency < Self-Care Demands Deficit R R Conditioning Factors Nursing Agency Conditioning Factors

Fawcett’s Criteria & Pertinent Questions for Evaluation of Nursing Theories

Explication of Origins ØAre the philosophical claims on which the nursing model is based explicit? Ø Yes, Orem’s Self-Care Framework is based on philosophical, theoretical, and scientific knowledge about human behavior Ø Philosophical claims stated in the form of: assumptions, presuppositions, and premises Ø Orem: “Philosophy will help you think about things, but will not tell your subject matter”

Explication of Origins Ø Are the scholars who influenced the model author’s thinking acknowledged and are bibliographic citation given? Ø YES; scholars from a variety of disciplines cited Bibliographical citations provided. Ø Aristotle, Thomas Aquinas, T. Parsons et al (1953), J. Macmurray (1957), B. J. F Lonergan (1958), M. B. Arnold (1960), M. Black (1962), T. Kotarbinski (1965), R. Harre (1970), Paul Weiss (1980), William A. Wallace (1983, 1996) Ø The Nursing Development Conference Group Ø Orem Study Group

Comprehensiveness of Content ØDoes the nursing model provide adequate descriptions of all four concepts of nursing’s metaparadigm? Ø Yes, the descriptions of all four of nursing’s metaparadigm concepts are adequate. Ø Nursing-Person Emphasis

Comprehensiveness of Content ØDo the relational propositions of the nursing model completely link the four metaparadigm concepts? Ø Yes, linkages are specified between concepts throughout the editions Ø However, only ONE statement links all 4 concepts- in the 2 nd edition of Orem’s book (1980)

“Nursing is made or produced by nurses. It is a service, a mode of helping human beings…Nursing’s form or structure is derived from actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments. This may be done by individuals or groups through their own actions under the guidance of a nurse or through the actions of nurses when persons have health-derived or health-related limitations that cannot be immediately overcome” (Orem, 1980, p. 5)

Comprehensiveness of Content ØIs the researcher given sufficient direction about what questions to ask and what methodology to use? Ø Purpose: to develop knowledge for the practical sciences of nursing… Ø Methods associated with: Empiricist research paradigm, Interpretive research paradigm – most consistent with Orem’s Framework Ø See Fawcett Table 8 -2, Table 8 -3 for examples

Comprehensiveness of Content ØDoes the educator have sufficient guidelines to construct a curriculum? Ø The framework has been used as a conceptual guide to nursing curriculums in a number of programs: Øassociate degree, Ødiploma, Øbaccalaureate, Ømasters and doctorate levels.

Comprehensiveness of Content ØDoes the administrator have sufficient guidelines to organize and deliver nursing services? Ø Yes, the Self-Care Framework provides ideas to guide: 1. The focus of nursing in the health-care institution 2. The purpose of nursing services 3. Characteristics of personnel 4. Settings for nursing services 5. Management strategies and administrative policies

Comprehensiveness of Content Ø Is the practitioner given sufficient direction to be able to make pertinent observations, decide that an actual or potential need for nursing exists, and prescribe and execute a course of action that achieves the goal specified in a variety of practice situations? Ø Purpose: to help people with health-related self-care deficits Ø Concepts encompass people across the lifespan and in a variety of diverse settings Ø Nursing Process: Professional-Technological Operations of Nursing Practice (see Fawcett Table 8 -1)

Logical Congruence Ø Does the model reflect more than one world view? Ø No, only that of ‘reciprocal interaction’ is noted Ø Does the model reflect characteristics of more than one category of nursing knowledge? Ø Characteristics are congruent with classification as a developmental model.

Logical Congruence Ø Do the components of the model reflect logical translation or reformulation of diverse perspectives? Ø Yes, the content of Orem’s Framework is logically congruent with her philosophical claims Ø Orem’s thinking was influenced by a variety of perspectives and resources from a range of disciplines

Generation of Theory Ø What theories have been generated from the nursing model? Ø Orem’s Self-Care Deficit Theory of Nursing Ø Middle-Range Theory of relating factors & concepts of selfcare agency & dependent-care agency of school-aged children & their mothers. (Gaffney & Moore, 1996). Ø Middle-Range Theory of Testicular Self-Examination (Fessenden, 2003).

Credibility of the Nursing Model: social utility, social congruence, social significance Ø Are education and special skill training required before applying the nursing model in nursing practice? Ø Yes, it is a rather unique framework in: focus, content, style and vocabulary. Ø Need to learn specific “style of thinking and communicating nursing” (Orem, 2001, p. 137) Ø Familiarity with language of theories of deliberate human action enhances understanding of Orem’s work.

Credibility of the Nursing Model: social utility, social congruence, social significance Ø Is it feasible to implement practice protocols derived from the nursing model and related theories? Ø Despite the need for special training and education, the implementation of Self-Care Framework-based practice protocols is feasible. Ø Patients of all ages, across diverse practice settings

Credibility of the Nursing Model: social utility, social congruence, social significance Ø To what extent is the nursing model actually used to guide nursing research, education, administration, and practice? Ø Actual application of Orem’s model takes many forms in all of the above arenas. Ø World-wide use: clinics, hospitals, home-health, health promotion practices & screenings

Credibility of the Nursing Model: social utility, social congruence, social significance Ø Does the nursing model lead to nursing activities that meet the expectations of the public and health professionals of various cultures and in diverse geographic regions? Ø Yes, it does; however, the emphasis on self-care may not be completely congruent with some people’s expectations of nursing practice

Credibility of the Nursing Model: social utility, social congruence, social significance Ø Does the application of the nursing model, when linked with relevant theories and appropriate empirical indicators, make important and positive differences in the health conditions of the public? Ø Yes, much empirical evidence supports Orem’s claim that nurses contribute to “maintaining health, preventing disease, and disability and restoring or maintaining life processes” by overcoming “health-associated human limitations for engagement in self-care or dependent-care” (Orem, 2001, p. 81).

Contributions to the Discipline of Nursing Ø What is the overall contribution of the nursing model to the discipline of nursing? Ø Orem’s framework presents an optimistic view of patients’ contributions to their health care and an explicit focus on what matters to nurses. Ø Orem has identified the domain and boundaries of nursing as a science and an art as well as nursing’s unique contribution to health-care.

Contrast of Theories Conceptual Model Person Environment Health Nursing Orem’s Self-Care Framework Self-care agent Therapeutic self-care demand made up of: 1 -universal SCRs 2 -developmental SCRs 3 -Health deviation SCRs The person’s external environment Soundness or wholeness of developed human structures & of bodily & mental functioning Definition: a helping service, creative effort to help people Goal: help people to meet their own therapeutic self-care demand Actions: wholly/partly, compensatory, supportiveeducative nursing systems. Assist by acting for or doing, guiding, physical &/or psychological support, providing a developmental environment, teaching. Roger’s Science of Unitary Human Beings A unitary human being, a patterned, open, pandimensional energy field An expression of the life process Definition: A learned profession that is both a science and an art. Goal: Help people achieve maximum well-being Action: Deliberative mutual patterning that involves environmental patterning to promote helicy, integrality, and resonancy. King’s Interacting Systems Framework Personal system: Focus on perception, self, growth & development, body image, time, space, learning Interpersonal system: Focus on interaction, communication, transaction, role, stress, coping. Social system: Focus on organization, authority, power, status, decision-making, and control. Internal/external Dynamic life experiences of a human being. Ability to function in social roles Definition: Perceiving, thinking, relating, judging, and acting vis-àvis the behavior of individuals who come to a nursing situation. Goal: Help individuals maintain their health so they can function in their roles Actions: A process of action, reaction, interaction, and transaction directed toward establishment of goals and goal attainment.

Peer Discussion “We need to order home health for Mr. Orem before he is discharged. ” The Orem Model of Nursing or Self Care Deficit Nursing Theory states nurses have to administer care when the patients cannot provide care to themselves.

Eastern Kansas VA Home Based Primary Care (HBPC) Mission Statement “…to provide compassionate care to veterans at home and in the community, promoting optimal independence of the veteran and support to the caregiver. ”

References Chinn, P. , & Kramer, M. (1991). Theory and Nursing (3 rd Ed. ). St. Louis: Mosby. Fawcett, J. (2005). Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories (2 nd Ed. ). Philadelphia, PA: F. A. Davis Company. Hartweg, D. L. (1995). Dorothea Orem: Self-Care Deficit Theory. In C. M. Mc. Quiston & A. A. Webb (Eds. ), Foundations of Nursing Theory: Contributions of 12 Key Theorists (pp. 139 -202). Thousand Oaks, CA: Sage Publications, Inc. Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (3 rd Ed. ). St Louis: Mosby. Marriner-Tomey, A. , & Alligood, A. (2002). Nursing Theorists and Their Work (5 th Ed. ). St Louis: Mosby. Orem, D. E. (2001). Nursing: Concepts of Practice (6 th ed. ). St. Louis, MO: Mosby, Inc. Wikipedia: Philosophy of action. (Oct. 7, 2008). Retrieved October 10, 2008, from Wikipedia: http: //en. wikipedia. org/wiki/Philosophy_of_action